=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215447206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMERY CRUZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2017
-----------------------------------------------------
Last Update Date | 10/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 21ST ST SE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-557-5197
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6332 DUERO PL NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-4992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-557-5197
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 8516
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------